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Contributors: N Barber, CPB, and N Britten initiated and designed the study. CAB and FAS helped to refine the initial design and collected the data. All five authors constructed the original coding frame. CAB and FAS carried out the coding. FAS and N Britten analysed the results for this paper. N Britten wrote the paper, guided by the comments of the other authors. N Britten will act as guarantor for the paper.
To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.
20 general practices in the West Midlands and south east England.
20 general practitioners and 35 consulting patients.
Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine.
14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing.
Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.
The importance of patients' involvement in health care is now being recognised by the medical profession.1 For patients to be involved their priorities must be identified and addressed. Most of the research about patients' preferences and expectations has been carried out at the population level using methods such as questionnaire surveys and focus groups.2–4 A consistent finding over the years has been patients' preferences for doctors who listen and encourage them to discuss all their problems. As patients' expectations are often context specific what is needed is research within the consultation to determine whether or not patients' preferences are being articulated and listened to.
Given that prescriptions are written in most general practice consultations, that doctor-patient communication about prescribing can be associated with discomfort for both parties,5,6 and the continuing problem of non-adherence to treatment,7 patients' priorities for prescribing are clearly an important focus.8 We conducted a qualitative study of prescribing decisions and patients' expectations in primary care. We aimed to identify misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicines.
Our paper is based on a Department of Health funded study, entitled “improving doctor-patient communication about drugs.” We aimed to conduct a detailed exploration of patients' expectations before consulting a general practitioner and to relate these expectations to the behaviour of both patients and doctors in the consultation and to subsequent use of medicines. Our study was conducted in 20 practices in the West Midlands and south east England. Ethical approval was obtained from 11 local research ethics committees. The methods have been reported in detail elsewhere.9
Twenty general practitioners were purposively selected from a group of 101 (16%) who responded positively to a letter outlining the research. The letter was sent to 645 general practitioners in 11 health authorities across the midlands and south east England. The sample was chosen to represent a diversity of doctors' gender, practice size, location (urban, rural, suburban), and fundholding status.
Patients over the age of 18, or the parents of patients under 18, were recruited from the participating practices in one of two ways. In 13 practices 44 patients were recruited by receptionists when booking appointments. Willing patients were then contacted by the researcher. The main criterion for recruitment was that patients should be consulting with a new problem (about which they had not consulted in the past six months) for which a prescribing decision was likely or possible. Few patients met this criterion, and so patients who wanted to discuss a previously prescribed medicine were also recruited. As this method produced insufficient patients with acute problems, 18 patients attending emergency surgeries were recruited from the final seven practices. Patients who had appointments were interviewed at home one or two days before the consultation, whereas emergency patients were interviewed in the practice before seeing the doctor.
The data for each patient were drawn from five sources: the audiotaped consultation, semistructured interviews with patients before and after the consultation, semistructured interviews with general practitioners after the consultation, and the interviewer's notes. In the preconsultation interview patients were asked about their experiences of illness, their expectations of the consultation, and their relationship with the doctor. In the postconsultation interview a week later patients were asked about what had happened in the consultation and about any medicines they had been prescribed. General practitioners were interviewed in their surgeries and asked about what had happened in each consultation and about their relationship with each patient. Both patients and doctors were asked if they were satisfied with the consultation.
The interviews and consultations were audiotaped and transcribed, the latter using transcription conventions that recorded details such as pauses and interruptions, which are not shown in the boxes. The analysis was carried out by all five authors who represent four disciplines (general practice, pharmacy, psychology, and sociology).10 Two authors (CAB and FAS)carried out a preliminary analysis of patients' expectations using the software package nudist, with the remaining three authors acting as second coders for 10% of the patients. Given the volume of data, a subsample of 35 patients was chosen for detailed analysis from the 62 complete cases. These patients were chosen to include both emergency and appointment surgeries (at least one case for each doctor) and a range of patient characteristics and medical problems. These 35 patients ranged in age from 3 months to 80 years, and 21 were female. Twenty three patients were exempt from prescription charges. As the preliminary analysis suggested widespread misunderstanding, the detailed analysis focused on this issue. Misunderstandings were identified for each of the 35 patients, which had potential or actual adverse consequences for taking medicines. These adverse consequences consisted of patients saying that they had not had their prescriptions dispensed or that they had not taken their medicines. They also included cases where the patient's actual or intended medicine taking did not agree with the prescription. The coding of misunderstandings was carried out independently by two authors (FAS and N Britten)and was based on the doctor and patient interviews as well as the consultations. Disagreements between coders were resolved by discussion. As we aim to find ways of improving doctor-patient communication, our analysis focused on negative rather than positive outcomes.
A meeting was held in each area to present a summary of the preliminary findings to the participating doctors within that area. Summaries were also sent to all the participating patients.
The preliminary analysis examined patients' expectations in relation to prescriptions. Overall, 26 of the 35 patients received prescriptions. Five patients received unwanted prescriptions, three did not receive a prescription they wanted, three did not obtain another wanted action such as a referral, 14 did not receive desired information or reassurance, four did not have their prescriptions dispensed, and seven did not take their medicine as intended by the doctor. Only eight of those whose expectations were not met expressed dissatisfaction with the consultation.
The detailed analysis showed that misunderstandings occurred in 28 of the 35 consultations. Box BoxB1B1 shows the categories of misunderstanding, with examples from the data. Misunderstandings arose (a) through lack of exchange of relevant information in both directions, (b) as a result of conflicting information or attributions, (c) when the patient failed to understand the doctor's diagnostic or treatment decision, and (d) from actions taken to preserve the doctor-patient relationship. In some cases there were several related misunderstandings that had potential or actual adverse consequences for taking medicine (see table on website). These misunderstandings occurred in both appointment and emergency surgeries and in long and short consultations.
Patients' participation in the consultation can take the form of the voicing of expectations and preferences and of the voicing of responses to doctors' actions and decisions. All the categories of misunderstanding we identified result from a lack of participation in these terms. Boxes BoxesB2B2 to toB5B5 provide brief case histories to illustrate the data. For clarity, only one category of misunderstanding is shown even if the case involved several misunderstandings.
Detailed analysis of behaviour in the consultation showed that most patients had agenda items that were not voiced.11 Many of the misunderstandings were based on inaccurate assumptions and guesses by both parties. Doctors either thought that they already knew the patients' preferences and therefore did not need to inquire about them or thought that such knowledge was unimportant. In particular doctors seemed unaware of the relevance of patients' ideas for successful prescribing and of the fairly widespread aversion to taking medicines. Patients did not often articulate this aversion, and doctors then assumed that patients wanted prescriptions when they did not. Prescriptions written in these circumstances often served to confirm to the patient the necessity of drug treatment. Even when patients managed to voice their concerns or beliefs these were often not explored by the doctor. Specifically, nine of the 21 patients wanting a prescription did not say so in the consultation. Eight of the 10 patients who did not want a prescription made no mention of this. None of the five patients who received unwanted prescriptions told the doctor that they did not want them. More generally, detailed analysis showed that these consultations could not be characterised as shared decision making.9
We have examined patients' perspectives and preferences at the level of individual consultations and identified ways in which lack of participation leads to misunderstandings that have actual or potential adverse consequences for taking medicines. We have not presented other kinds of misunderstanding in this paper. The identification of these misunderstandings is based on interview data from both parties as well as consultation data. Models of shared decision making emphasise the need for an exchange of information, and the findings show the consequences of the failure to exchange information.12,13 Both parties to the consultation have relevant information to exchange and it was not possible to make judgments about which party contributed most to each misunderstanding. The findings show specific ways in which patients' expectations are not elicited or expressed and underline the importance of researching patients' priorities at the consultation level. The fact that general practitioners sometimes write inappropriate prescriptions to preserve relationships with their patients is well established,14 and these results confirm the adverse consequences of this. The findings also confirm the conclusion reached by others that asking patients about satisfaction is an insufficient way of assessing the outcome of consultations.
The participating doctors were a selected sample of general practitioners willing to participate in the research and who may have had a particular interest in communication. If these doctors have misunderstandings with their patients it is likely that less interested doctors would also experience these problems. The doctors were chosen to represent a range of locations and types of practice, and misunderstandings occurred across the whole sample.
It is well established that patients prefer doctors who listen and encourage them to discuss all their problems, but also that patients are often passive in consultations
This qualitative study, having captured patients' and doctors' perspectives and the actual content of consultations, shows a range of misunderstandings and their actual or potential adverse consequences for taking medicines
These misunderstandings seem to be associated with patients' lack of participation in the consultation and are often based on inaccurate guesses and assumptions on the part of both doctors and patients
An educational intervention is being developed on the basis of these findings
Clinicians may be tempted to think that they know their patients well enough not to have to verify their own assumptions. Our data suggest that many assumptions made by doctors, although reasonable in themselves, are not correct in particular circumstances, and that doctors need to check their assumptions in each consultation. It has already been established that doctors' perceptions of patients' expectations are a major influence on prescribing decisions.15,16 Although we have focused on misunderstandings, we also identified examples of good practice. In particular, one doctor asked patients directly what they thought about taking medicines. In this way misunderstandings were avoided, and in one case this doctor gave the patient a deferred prescription, which was an acceptable outcome for the patient.17 It is clearly difficult to avoid all misunderstandings within the time constraints of most general practice consultations, although some doctors in our study consultations did succeed in doing so.
The question remains as to whose responsibility it is to improve communication in the consultation. Arguments can be made in favour of changing either doctors' or patients' behaviour, and changes on both sides are likely to be necessary. However, given the power imbalance in many consultations the onus would seem to be on doctors to elicit patients' ideas and expectations thereby showing that this information is a valuable and necessary contribution to the consultation. In addition to listening, doctors also need to ask the right questions. We are currently developing an educational intervention that builds on these findings.
We thank all the patients, receptionists, and general practitioners who took part in the study.
Funding: The study on which this paper is based is funded by the Department of Health as part of the prescribing research initiative. The views expressed in this paper are those of the authors and not the Department of Health.
Competing interests: None declared.
website extra: A table showing the categories of misunderstandings for each patient appears on the BMJ's website www.bmj.com